Colorectal cancer screening: A review of current knowledge and progress in research.

Colorectal cancer (CRC) is one of the most prevalent malignancies worldwide, being the third most commonly diagnosed malignancy and the second leading cause of cancer-related deaths globally. Despite the progress in screening, early diagnosis, and treatment, approximately 20%-25% of CRC patients still present with metastatic disease at the time of their initial diagnosis. Furthermore, the burden of disease is still expected to increase, especially in individuals younger than 50 years old, among whom early-onset CRC incidence has been increasing. Screening and early detection are pivotal to improve CRC-related outcomes. It is well established that CRC screening not only reduces incidence, but also decreases deaths from CRC. Diverse screening strategies have proven effective in decreasing both CRC incidence and mortality, though variations in efficacy have been reported across the literature. However, uncertainties persist regarding the optimal screening method, age intervals and periodicity. Moreover, adherence to CRC screening remains globally low. In recent years, emerging technologies, notably artificial intelligence, and non-invasive biomarkers, have been developed to overcome these barriers. However, controversy exists over the actual impact of some of the new discoveries on CRC-related outcomes and how to effectively integrate them into daily practice. In this review, we aim to cover the current evidence surrounding CRC screening. We will further critically assess novel approaches under investigation, in an effort to differentiate promising innovations from mere novelties.

Inflammatory myofibroblastic tumor presenting as a subepithelial lesion of the colon.

We present the case of a 42-year-old male admitted to the emergency department for a 15-day history of diarrhea, with bloody stools in the past 7 days. The patient denied abdominal pain or distension as well as any constitutional symptoms. On physical examination he presented good general health condition, with abdomen slightly tender in the lower quadrants; digital rectal examination was remarkable for the presence of dark blood. Laboratory evaluation revealed new onset normocytic anemia (Hb 10.8 g/dL, MCV 89 fL) and RCP of 3.3 mg/dL. Colonoscopy was performed, which showed a large cecal subepithelial lesion, with surface ulcerations. Histology reported mixed inflammatory infiltrate but no malignancy. Further investigation was carried out with an abdominal and pelvic computerized tomography that, other than the cecal mass, showed multiple infracentimetric mesenteric lymph nodes. A right laparoscopic hemicolectomy was performed. Pathological analysis led to the unusual diagnosis of inflammatory myofibroblastic tumor (IMT) of the colon. There was no sign of recurrence after 6 months of follow-up.

Inflammatory myofibroblastic tumor presenting as a subepithelial lesion of the colon

We present the case of a 42-year-old male admitted to the emergency department for a 15-day history of diarrhea, with bloody stools in the past 7 days. The patient denied abdominal pain or distension as well as any constitutional symptoms. On physical examination he presented good general health condition, with abdomen slightly tender in the lower quadrants; digital rectal examination was remarkable for the presence of dark blood. Laboratory evaluation revealed new onset normocytic anemia (Hb 10.8 g/dL, MCV 89 fL) and RCP of 3.3 mg/dL. Colonoscopy was performed, which showed a large cecal subepithelial lesion, with surface ulcerations. Histology reported mixed inflammatory infiltrate but no malignancy. Further investigation was carried out with an abdominal and pelvic computerized tomography that, other than the cecal mass, showed multiple infracentimetric mesenteric lymph nodes. A right laparoscopic hemicolectomy was performed. Pathological analysis led to the unusual diagnosis of inflammatory myofibroblastic tumor (IMT) of the colon. There was no sign of recurrence after 6 months of follow-up (AU)

Colorectal Cancer Screening: What Is the Population's Opinion.

BACKGROUND: Colorectal cancer (CRC) is the first cause of death by cancer in Portugal and mortality has been increasing in the last 30 years. MATERIALS AND METHODS: During a raising awareness campaign performed by our Gastroenterology Department, in Setúbal, Portugal, an anonymous written questionnaire was developed and presented in order to evaluate the population's knowledge and attitude regarding CRC screening. RESULTS: The following results were reported: 140 persons; mean age 54.6 years; 61.4% women; 22.1% had a family history of colorectal cancer. The main risk factors mentioned by the respondents were family history of CRC, previous history of intestinal polyps, and intestinal infection. Screening was considered useful by all respondents. About 60% of the respondents had been counselled, at least, on one screening technique, mainly by their general practitioner: colonoscopy in 31, fecal occult blood test in 44, and flexible sigmoidoscopy in 9. Most of the respondents had had the appropriate screening test, according to their age and family history. Fourteen of the respondents had not undergone the recommended screening. Their answers showed that this was due to fear of pain/discovering a disease as well as embarrassment. CONCLUSION: Although the majority of the respondents were aware of the importance of CRC screening, results show that there are still several misconceptions about risk factors, fear, and reluctance concerning the screening techniques. Awareness actions are useful to clarify possible questions and inform the population in order to increase compliance with screening.

INTRODUÇÃO: O cancro colorretal (CCR) é a primeira causa de morte por cancro em Portugal, com uma mortalidade que tem aumentado nos últimos 30 anos. MATERIAIS E MÉTODOS: Durante uma acção de sensibilização levada a cabo por profissionais de saúde do Serviço de Gastrenterologia, em Setúbal, Portugal, foi realizado um inquérito escrito, anónimo, no sentido de avaliar os conhecimentos e atitudes da população face ao CCR. RESULTADOS: 140 indivíduos; idade média 54.6 anos; 61.4% mulheres; 22.1% tinham pelo menos 1 familiar com CCR. Os factores de risco para CCR mais referidos foram a presença de pólipos e a história familiar. A infecção intestinal foi considerada como um factor de risco para CCR por 74% dos inquiridos, sendo que o rastreio foi considerado útil por todos. Tinha sido recomendado pelo menos um exame de rastreio a cerca de 60% dos participantes, a maioria por indicação do médico assistente de medicina geral e familiar: colonoscopia total em 31, pesquisa de sangue oculto nas fezes em 44 e rectossigmoidoscopia em 9. Atendendo à idade e história familiar, a maioria efectuou um rastreio apropriado. Catorze pessoas não efectuaram o rastreio aconselhado; os motivos mais apontados foram o medo da dor/descobrir uma doença e vergonha. CONCLUSÃO: Embora a maioria dos inquiridos estivesse alerta para a importância do rastreio do CCR, persistem muitas ideias erradas em relação a factores de risco, receios e reticências quanto à realização dos exames de rastreio. Acções de sensibilização são úteis para clarificar dúvidas e informar a população no sentido de aumentar a adesão ao rastreio.

Ball valve syndrome caused by a giant gastric Vanek’s tumor

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Ball valve syndrome caused by a giant gastric Vanek's tumor.

Inflammatory fibroid polyps (Vanek's tumor) are rare, accounting for 0.1% of all gastric polyps. This letter describes an unusual case of an intermittent gastric outlet obstruction by a large Vanek's tumor.

Seronegative Intestinal Villous Atrophy: A Diagnostic Challenge.

Celiac disease is the most important cause of intestinal villous atrophy. Seronegative intestinal villous atrophy, including those that are nonresponsive to a gluten-free diet, is a diagnostic challenge. In these cases, before establishing the diagnosis of seronegative celiac disease, alternative etiologies of atrophic enteropathy should be considered. Recently, a new clinical entity responsible for seronegative villous atrophy was described-olmesartan-induced sprue-like enteropathy. Herein, we report two uncommon cases of atrophic enteropathy in patients with arterial hypertension under olmesartan, who presented with severe chronic diarrhea and significant involuntary weight loss. Further investigation revealed intestinal villous atrophy and intraepithelial lymphocytosis. Celiac disease and other causes of villous atrophy were ruled out. Drug-induced enteropathy was suspected and clinical improvement and histologic recovery were verified after olmesartan withdrawal. These cases highlight the importance for clinicians to maintain a high index of suspicion for olmesartan as a precipitant of sprue-like enteropathy.

Systemic mastocytosis: A rare cause of non-cirrhotic portal hypertension.

Mastocytosis is a clonal neoplastic disorder of the mast cells (MC) that can be limited to the skin (cutaneous mastocytosis) or involve one or more extracutaneous organs (systemic mastocytosis). The clinical manifestations of mastocytosis are heterogeneous ranging from indolent disease with a long-term survival to a highly aggressive neoplasm with survival of about 6 mo. Although liver involvement in aggressive systemic mastocytosis (ASM) is relatively common, the development of portal hypertension with or without cirrhosis is rare. We report a case of ASM without skin involvement in a 72-year-old caucasian male who presented with non-cirrhotic portal hypertension based on clinical, analytical, imagiological and endoscopic findings. Given the hematological picture, the correct diagnosis was established based on ancillary tests for MC using bone marrow aspirates and biopsy. Extensive involvement of the liver and gastrointestinal tract was histologically documented. The disease progressed rapidly and severe pancytopenia and recurrent upper gastrointestinal bleeding became the dominant problem. This case illustrates the challenge in establishing a diagnosis of ASM especially when the clinical picture is atypical and without skin involvement. Gastroenterologists should consider infiltrative disease, particularly systemic mastocytosis, as a differential diagnosis in a clinical case of portal hypertension of unknown etiology.

Metabolic syndrome and colorectal neoplasms: An ominous association.

AIM: To evaluate the association of metabolic syndrome (MS) and colorectal cancer and adenomas in a Western country, where the incidence of MS is over 27%. METHODS: This was a prospective study between March 2013 and March 2014. MS was diagnosed according to the National Cholesterol Education Program-ATP III. Demographic characteristics, anthropometric measurements, metabolic risk factors, and colonoscopic pathologic findings were assessed in patients with MS (group 1) who underwent routine colonoscopy at our department. This data was compared with consecutive patients without metabolic syndrome (group 2), with no differences regarding sex and age. Patients with incomplete colonoscopy, family history, or past history of colorectal neoplasm were excluded. Informed consent was obtained and the ethics committee approved this study. Statistical analysis was performed using Student's t-test and χ(2) test, with a P value ≤ 0.05 being considered statistically significant. RESULTS: Of 258 patients, 129 had MS; 51% males; mean-age 67.1 years (50-87). Among the MS group, 94% had high blood pressure, 91% had increased waist circumference, 60% had diabetes, 55% had low high-density lipoprotein cholesterol level, 50% had increased triglyceride level, and 54% were obese [body mass index (BMI) 30 kg/m(2)]. 51% presented 4 criteria of MS. MS was associated with increased prevalence of adenomas (43% vs 25%, P = 0.004) and colorectal cancer (13% vs 5%, P = 0.027), compared with patients without MS. MS was also positively associated with multiple (≥ 3) adenomas (35% vs 9%, P = 0.024) and sessile adenomas (69% vs 53%, P = 0.05). No difference existed between location (P = 0.086), grade of dysplasia (P = 0.196), or size (P = 0.841) of adenomas. In addition, no difference was found between BMI (P = 0.078), smoking (P = 0.146), alcohol consumption (P = 0.231), and the presence of adenomas. CONCLUSION: MS is positively associated with adenomas and colorectal cancer. However, there is not enough information in western European countries to justify screening in patients with MS. To our knowledge, no previous study has evaluated this association in Portuguese patients.

Appropriateness of outpatient gastrointestinal endoscopy in a non-academic hospital.

AIM: To assess the appropriate use and the diagnostic yield of upper gastrointestinal endoscopy and colonoscopy in this subgroup of patients. METHODS: In total, 789 consecutive outpatients referred for gastrointestinal (GI) endoscopy [381 for esophagogastroduodenoscopy (EGD) and 408 for colonoscopy] were prospectively enrolled in the study. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines were used to assess the relationship between appropriateness and the presence of relevant endoscopic findings. RESULTS: The overall inappropriate rate was 13.3%. The indications for EGD and colonoscopy were, respectively, appropriate in 82.7% and 82.6% of the exams, uncertain in 5.8% and 2.4% and inappropriate in 11.5% and 15%. The diagnostic yield was significant higher for EGDs and colonoscopies judged appropriate and uncertain when compared with those considered inappropriate (EGD: 36.6% vs 36.4% vs 11.4%, P = 0.004; Colonoscopy: 24.3% vs 20.0% vs 3.3%, P = 0.001). Of the 25 malignant lesions detected, all but one was detected in exams judged appropriate or uncertain. CONCLUSION: This study shows a good adherence to ASGE guidelines by the referring physicians and a significant increase of the diagnostic yield in appropriate examinations, namely in detecting neoplastic lesions. It underscores the importance that the appropriateness of the indication assumes in assuring high-quality GI endoscopic procedures.

[Malignant peritoneal mesothelioma]. / Mesotelioma peritoneal maligno.

Malignant peritoneal mesothelioma is a rare tumor arising from the mesothelial cells of this serosal membrane. The authors report a case of a female patient referred to our hospital for ascites of unknown etiology. As all the exams requested were negative, the patient underwent a diagnostic laparoscopy with biopsies of multiple peritoneal nodules. Histologic examination confirmed the diagnosis of malignant peritoneal mesothelioma. A cytoreductive surgery in combination with hyperthermic intraperitoneal chemotherapy was performed. After four months of the procedure the patient remains asymptomatic.

A comparative study of two methods of colonic cleansing before colonoscopy.

BACKGROUND/AIMS: good colonic preparation is essential to perform a complete and safe colonoscopy. The preparation used in the Endoscopy Unit was adopted after testing it against the classic 4-liter polyethylene glicol (PEG) preparation (Klean-Prep). Recently a new 3-liter PEG preparation was commercialised in Portugal, Endo-Falk, which appeared to be simpler and effective. The present study compared the preparation we usually use (a combination of 4 tablets of bisacodyl with 2-liter PEG and enemas) with this new preparation. METHODOLOGY: we enrolled 305 patients in 2 groups. Group 1 was given our usual preparation, as described above and group 2 was given the new 3-liter preparation, Endo-Falk. All patients were ambulatory, and only patients undergoing total colonoscopies were included. Patients with benign or malignant stenosis and patients who had previously undergone colorectal resection were excluded. Preparation was graded as good when there were no stools and little liquid in the colon, fair when there were stools or liquid that could be aspirated and did not obscure the mucosa and bad when stools or excess liquid prevented an adequate view of the surface or precluded polipectomy. RESULTS: The present study included 164 male and 141 female patients, with a mean age of 61.3 years (no difference between the demographic data). In group 1 the preparation was good in 57.5%, fair in 28.5% and bad in 14% of patients and in group 2 the preparation was good in 33.1%, fair in 48.9% and bad in 18% (p < 0.001). Colonoscopies were complete in 89.9% of all patients. CONCLUSIONS: The usual preparation was better than the new 3-liter PEG solution.